The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?

The patient newly diagnosed with heart failure whose pulse oximetry is 94% on 2L oxygen.

A patient scheduled for echocardiogram who has altered level of consciousness and restlessness.

The patient who has dyspnea on exertion but wants to be discharged against medical advice.

The patient whose ejection fraction (EF) is 50% and has 2+ bilateral lower extremity edema.

Answer and Explanation

The Correct Answer is B

Choice A reason: The patient with heart failure whose pulse oximetry is 94% on 2L oxygen is stable at the moment. While they require monitoring, they do not take immediate priority over the patient with altered consciousness.

Choice B reason: Altered level of consciousness and restlessness are critical symptoms that require immediate assessment. These could indicate a life-threatening condition such as hypoxia, electrolyte imbalance, or stroke, necessitating prompt evaluation and intervention.

Choice C reason: The patient with dyspnea on exertion who wants to be discharged against medical advice is important, but altered consciousness takes precedence due to its potential severity.

Choice D reason: The patient with an ejection fraction of 50% and 2+ bilateral lower extremity edema is stable and does not require immediate intervention compared to the patient with altered consciousness.

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Correct Answer is B

Explanation

Choice A reason: Encouraging the patient to engage in moderate exercise to improve circulation is not appropriate during a sickle cell crisis. Exercise can increase oxygen demand and exacerbate the crisis. Rest and avoiding strenuous activities are recommended.

Choice B reason: Applying warm compresses to the painful areas can help reduce discomfort and improve circulation. Warmth helps relax muscles and dilate blood vessels, providing relief during a sickle cell crisis.

Choice C reason: Suggesting the patient drink caffeinated beverages to stay alert and energized is not appropriate. Caffeine can cause dehydration, which can worsen the sickling of red blood cells. Maintaining hydration with water and non-caffeinated beverages is essential.

Choice D reason: Recommending cold showers to help reduce pain and swelling is incorrect. Cold can cause vasoconstriction, which can worsen pain and reduce blood flow to affected areas. Warm compresses are preferred.

A. Acute hemolytic B. Allergic C. Anaphylactic D. Circulatory overload

Correct Answer is B

Explanation

Choice A reason: Acute hemolytic reactions are severe and typically present with symptoms such as fever, chills, flank pain, hemoglobinuria, and shock. The patient's mild symptoms of itching and a localized rash do not match the severe presentation of an acute hemolytic reaction.

Choice B reason: Allergic reactions to blood transfusions are common and usually present with symptoms such as itching, hives, and localized rash. The patient's vital signs and physical assessment showing mild itching and a rash on the arms are consistent with an allergic reaction.

Choice C reason: Anaphylactic reactions are severe allergic reactions that involve respiratory distress, hypotension, and shock. The patient's mild symptoms do not indicate an anaphylactic reaction.

Choice D reason: Circulatory overload presents with symptoms such as dyspnea, orthopnea, hypertension, and pulmonary edema. The patient's symptoms of itching and a rash do not align with circulatory overload.

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The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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